In the windowless world of the ER, Anil was disconnected from the rest of his intern class. Emergency Department staff were not permitted to leave their posts to attend grand rounds or lectures with other residents, or even to go to the cafeteria. For lunch, he often settled for a protein bar from the vending machine while waiting for a consult. When the residents ordered pizza, Eric insisted upon a Meat Lover’s pie, eating two slices at the same time, one flipped on top of the other like a sandwich. It was difficult for Anil to relate to Eric, so different from the physicians he’d known back in India. Loud and brash, Eric had a prominent scar on his forehead he said he’d got kitesurfing, a cross between two other dangerous sports Anil had never heard of.
Among the dozen interns and residents working the ER, Anil was surprised to see that nearly half were women. He avoided them, unsure how to behave, but was more comfortable interacting with the female nurses, as he had done in India. Anil was the only foreign student in the group, and one of the few who weren’t white. Like Anil, the great majority of patients at Parkview weren’t white either. Far from the bucolic paradise Anil had envisioned back in India, Parkview turned out to be the hospital of last resort for the city’s poorest. Those with no health insurance, no money, and no regular doctor showed up at Parkview, particularly the ER. There was the homeless woman who listed her address as “Planet Earth” and wore, upon her disheveled nest of hair, a carefully constructed tinfoil hat, which she refused to remove for the examination. And the man reeking of liquor, with a nose reddened by a long history of alcoholism, who nevertheless insisted he hadn’t been drunk when he fell down and cut his forehead on broken glass.
By the end of each day, Anil was not only physically exhausted but mentally drained. He was overwhelmed by his patients’ evasion and mistrust, the desperation in their eyes and voices, the scent of urine and filth. The first thing he did when he got home, well after 10 p.m. most nights, was take a very long shower, scrubbing himself until the fragrant soap flooded his senses.
Interns were expected to study at home in the evenings, and Anil had been accumulating a reading list. Every night he left the hospital with the intention of working through his list, but after being on his feet for twelve hours, he’d barely make it through the first topic before falling asleep. When his alarm sounded at 5 a.m., he’d wake up in bed, surrounded by books, with his specs and the overhead light still on.
“HAVE YOU seen Eric Stern?” a nurse asked Anil, the only white coat in the vicinity of the triage desk before morning rounds. “I’ve got an urgent patient.”
“I can take it,” Anil said, reaching for the chart.
“You sure?” She peered at his ID badge. “It’s not a minor.”
Anil took the chart. He’d been looking for an opportunity to present his own case on rounds, to make an impression on the attending. Behind Curtain 6 he found John Doe, a young man dressed in street clothes, his head fallen to one side and his mouth hanging open.
“Sir?” Anil shook the patient’s shoulder and shone a light into his eyes. His pupils were constricted, his respirations shallow. No alcohol on his breath, nothing on his body other than a few residual marks of healed scabies on his arms. Anil’s pulse raced as the differential diagnosis ran through his mind. Brain stem hemorrhage. Pulmonary embolism. He tried hoisting the patient up but was surprised by how limp and heavy his body was. The patient dropped back onto the hospital bed with a thud, his head falling to the other side.
Anil yanked open the curtain and yelled for an intubation cart, just as the ER attending rounded the corner with Eric and the rest of the team.
“Patel, where you been?” Eric barked. “Rounds start at seven o’clock. Sharp.”
“I-I-I have a critical patient here,” Anil said. “Might n-n-need to intubate.” He felt a rush of shame as he sputtered out the words.
“Whoa,” the attending said. “Slow down. Let’s see what we have here. How’s his breathing?”
“Shallow respirations—”
“But he’s breathing independently, right? Let’s check his airway.” The attending placed a tongue depressor deep into the patient’s mouth and John Doe, in his first visible sign of life, gagged on it. The attending turned to the rest of the team. “From that reflex, we know he’s protecting his airway. No need to intubate.” He shot a look at Anil. “Heart rate?”
Fifty-five, Anil recalled, but fs were the worst for him. He could already feel them stopping up behind his lips, ready to trip over each other if he opened his mouth, so instead of speaking he watched the attending listen to the patient’s heart with his own stethoscope. “Heart rate’s fifty-six—normal. What else? BP?”
“I di-di-didn’t check.” Anil tried to breathe slowly as the heat rose to his face.
The attending turned to the rest of the team. “Can anybody who paid attention the first week of med school tell me the initial steps for a nonresponsive patient?”
The tan-blazer guy from orientation spoke up. “Airway, breathing, circulation.” Trey Crandall, Anil read on his name badge.
The attending turned back to Anil. “ABC. Sound familiar? And did you notice anything in your physical exam, Dr. Patel?” A hard edge had crept into his voice. “You did do a physical exam? Anything strike you as unusual about the patient’s arms?” He grabbed John Doe’s wrist and held it up for everyone to see.
“Recent s-s-scabies infection . . .” Anil’s head was burning, and there was a pulsing pain behind his eyes. He searched his memory for anything that might have developed from scabies, rummaging in his pocket for the index cards he’d prepared for this rotation.
“Scabies?” The attending smirked. “Anyone else?”
The mood at Curtain 6 turned somber as the urgency of the patient’s medical condition was replaced with Anil’s public humiliation. The incessant beeping of a monitor behind the next curtain marked a few moments before Trey Crandall jumped in, eager to fill the void created by Anil’s squandered opportunity. “Track marks?” he offered.
The attending dropped the patient’s arm and pointed at Trey. “Bingo! This type of patient is a frequent flyer in our ER, Patel. These marks are obvious signs of an intravenous drug user. I bet his tox screen will come back positive for gamma-hydroxybutyric acid. High doses of GHB, also known as Liquid E, can cause rapid unconsciousness. He’ll be up in an hour or two, screaming and cussing like everyone else. Until then, roll him on his side so he doesn’t aspirate, and check his vitals every half hour.”
As the team filed out behind the attending, Eric Stern stopped directly in front of Anil. “Getting a little ahead of yourself, Patel. Next time, tell the triage nurse to page me when you don’t know what the hell you’re doing.”
On his way out, Charlie placed his hand on Anil’s shoulder. “Okay, mate.” The unexpected touch caused Anil’s eyes to fill. He bit down on his tongue.
ANIL WAS five years old when he first began to stammer. At school, the cruelest children taunted him. The worst of the lot was a large, dim-witted boy named Babu, whose father was a known drunkard who couldn’t hold a job, though he had once worked as one of Papa’s field hands. Whenever the teacher’s back was turned, Babu made hissing sounds at Anil, until the other boys joined in and they resembled a pack of angry snakes.
One day, as the students began filing out of the classroom, the teacher asked Anil to stay behind—Babu launching one last hiss at him. The teacher held out a thick volume, bound in fabric too fine for a schoolbook. Anil ran his hand over the tightly wound threads of the indigo cover. He fanned through the pages, releasing a musty odor.
“Do you know it?” the teacher asked.
Anil nodded, recognizing the title from his father’s collection—the autobiography of Mahatma Gandhi.
“Practice reading those passages I marked. When you’re ready, you can do a recitation for the class.”
This notion terrified Anil but he dutifully took the book. Each afternoon he left the Big House, walked around the rice paddies, over
the low hill, and out to his favorite banana tree, where he stayed until the sun sank low in the sky. He sat under that tree and read the passages his teacher had marked until the words came smoothly and were committed to memory. Finally, Anil stood under the tree, performing the passages for an audience of crickets and toads. Then he knew that, at least in one isolated place, with one set of words, he could speak clearly. In this way, Anil was able to largely overcome his stutter by the age of nine, and with that accomplishment, he learned he could do anything.
AT THE end of the shift, Anil sat in the workroom as Charlie changed out of his scrubs. “I can’t do it,” Anil said. “I’ve been working toward this my whole life and now I’m f-f-f-failing.” He closed his eyes and rubbed at them.
“C’mon, mate,” Charlie said. “You just had a bad day.”
Anil shook his head. “You didn’t see Stern’s face. I’m going to fail out of the program. I’ll have to go home, and I won’t be qualified to practice, and all the training programs in India are already closed.” He pictured the expression on Papa’s face if he went home a failure.
Charlie pulled up a chair across from Anil and sat on it backwards, his chin resting on the top edge. “Listen, mate, take a deep breath. One day at a time. What do you have to do for tomorrow? Finish today’s reading and prepare for rounds, right? So let’s do that. Don’t worry about anything else tonight, okay?”
Beginning that night, Anil and Charlie went to a nearby diner to work through their reading lists every day after leaving the hospital. They kept their books in their cars and met up in the same burgundy vinyl booth in the back corner, away from the kitchen and the other patrons. Their regular waitress was a thin older woman named Joy whose raspy voice intimated a lifetime of smoking. She learned their orders: the meatloaf platter for Charlie, and the same without meatloaf for Anil. The mashed potatoes and vegetable medley were unremarkable, but at this diner Anil had discovered gravy, which he poured over everything, along with one of the many hot sauces kept on the table.
“Mate, this is amazing!” Charlie exclaimed a couple of weeks later when Anil presented him with a full set of his color-coordinated index cards, each containing notes of symptoms, differential diagnoses, recommended tests, and treatments. “How . . . When did you do all this?” Charlie flipped one of the cards over, glancing at the journal references on the back.
Anil shrugged, a little sheepish. “I started in medical college and just keep adding to them.” He hadn’t made a practice of sharing his notes, given how competitive medical college had been. But Charlie was different, easier to get along with than many of the other interns. Perhaps it was the relaxed nature he claimed was endemic to all Aussies, or that he was older than the rest of the class. Charlie had worked as a biomedical engineer in Sydney for several years and was planning to apply to business school when he went to America to go backpacking in Monument Valley. With his experience in the Australian outback, Charlie was soon leading expedition groups through the canyons. During that year, spent in close proximity to both nature and people, Charlie decided climbing the corporate ladder at a medical-device company wasn’t for him after all, and applied to medical school instead.
“Seriously, Patel, this is a secret weapon.” Charlie fanned through the stack of cards. “We’ll have the ER mastered in no time. Thank you, mate, really generous of you to share these.” He reached over and slapped Anil’s shoulder.
Anil smiled as he picked up a bottle of bright green chili sauce and untwisted the cap. “No problem.” He was happy to do something for Charlie, the only one of his peers he felt he could trust. One day, a few weeks earlier, when he had been changing scrubs in the locker room after getting soaked by a wayward urine catheter, he’d overheard some guys talking as they tossed a football back and forth on the other side of the room. “Have you seen that foreign guy on rounds?” a disembodied voice said in between the thwacks of the ball being caught. Anil froze in place, one foot hovering over his pant leg.
“Who?” He recognized Trey’s unmistakable baritone.
“Patel. He’s got these little index cards with notes from every obscure journal article. Can’t think on his feet, can’t answer a question worth a damn. You should’ve seen the attending take him apart when he wanted to look something up before answering.” Anil held his breath, terrified someone would walk around the lockers and see him there, pantless.
“Besides,” a third person said, “even when he has an answer, who the hell can understand him?” All three of them broke into laughter, the dissonance reverberating in Anil’s ears. He didn’t know if it was his accent they were mocking, his stutter, or his inadequate presentations, nor did it matter.
ANIL EXPECTED things to improve after his first rotation in the ER, but he came to discover that each monthly rotation had its own particular horrors. The ER was only the worst in terms of the sheer volume of new patients to clear every day. The general medical wards were an incessant juggling act of demanding patients. Gastroenterology offered frequent opportunities to be vomited upon, as well as the occasional explosion of diarrhea. Every month brought not just a new realm of medicine but a new set of supervisors to challenge and humiliate him, and a new set of peers eager to step over each other to score points.
A sense of utter exhaustion had overtaken Anil’s life. Fatigue unraveled itself into a full-body experience: First his head became foggy, then his shoulders sagged and he found himself leaning against the wall. At some point, his eyes began burning and watering, for which he kept tissues and eye drops in his coat pocket at all times. After he’d been on his feet for twelve hours or more, he felt a deep ache in his knees, which would stay with him all night if he was on call, and which could not be alleviated except by eight hours of undisturbed sleep, whenever it finally came.
Six days a week, Anil roused himself in a haze and returned to the hospital, determined to prove he could do this job for which he’d so long prepared. He had expected to work hard during his internship, and this he didn’t mind, but he did miss hearing words of praise once in a while, or the inner satisfaction of getting something right. He missed feeling appreciated, or simply respected, by patients. In India, his grateful patients had brought him so many sweets that Anil gained three kilos in the first month. Here, his patients were distrustful and combative. Whether this was equally true for all doctors, or worse for Anil, he couldn’t be sure.
Within a few months, Anil had given up the elusive hope of finding proficiency in his work. Instead, he developed ways of coping: moving through his patients with brisk efficiency, remembering them by condition or room number instead of learning their names. Charlie’s advice to get through one day at a time became his new mantra. Every night, Anil revisited the impish blue Krishna calendar pinned to his bedroom door, wondering, before placing a black gash across the date, if this daily glance at the deity would qualify as prayer in his mother’s eyes. Midway through his internship year, his hierarchy of goals had changed. Just like the human body under duress needs oxygen and fluids before all else, Anil was now just trying to survive.
3
LEENA TRIED TO MAINTAIN A NEUTRAL EXPRESSION AS PIYA grinned and clutched a pillow to her chest. “Come, come! Tell me,” Piya said, making herself comfortable on her bed.
Leena sat at the other end of the bed, facing Piya, her legs outstretched. She shrugged but a smile crept through regardless. Piya had always been able to draw things out of her, despite being two years younger.
They had been friends from the time they were old enough to stray out of their neighboring homes and find each other outdoors. Leena had no brothers or sisters, so she relished the company of Piya and her siblings. Anil was the unspoken leader of their little group, always looking out for his four younger siblings and setting rules of play that were fair to everyone. Leena couldn’t say quite why she and Anil had gravitated toward each other in the first place. Perhaps it was because they were both quiet as children: she, an only child, accustomed to playing in
her own imagination; Anil more absorbed with his books than with rowdy games of cricket like the other boys and reluctant to speak because of his stutter. Whatever the reason, when he discovered a waterfall at the end of the river, she went with him to swim under it. And when she wanted to climb the tallest coconut tree on the land, he followed. After a while, they could spend an entire afternoon together without many words.
Piya slapped Leena’s knee. “Tell me everything, hear? Every little detail. Come on. What’s he like?”
Leena shrugged again. “I . . . I don’t know, really.” It was true, she knew almost nothing about the man who might become her husband in a few weeks’ time. She had met Girish once, and things had moved quickly since then.
A few months earlier, Leena’s parents had decided it was time to seek a husband for her. She was twenty and had finished her schooling. Leena enjoyed living with her parents, helping her mother with the cooking and their home, some days accompanying her father in the fields. The land surrounding them was her true home: the green expanses of the rice paddies, the soaring trees, the rise of the mountains in the distance. Leena was in no hurry to get married, or to leave her parents on their own. Her father had begun suffering from one ailment after another: he was short of breath, his knees were weak, and his back became sore after a few hours in the fields.
But Leena knew it was time: she might still feel like a girl, but she was the right age to marry, and in a few more years she would be too old. Besides, she didn’t have many other choices. She had barely scraped her way through the tenth standard at school; she wasn’t a good student like Anil, though he’d tried to help her with her studies when they were younger. “How about this?” he would say, explaining a math problem in a new way. Anil studied harder than anyone, as if he were propelled by an inner motor toward some distant horizon he alone could see.